Communication, Collaboration and Care Coordination: The Three-Point Guide to Cancer Care Provision for Aboriginal and Torres Strait Islander Australians

Continued relationships and trust

Patient follow-up and provision of holistic care

General practitioner (GP) as central point

Staff workload resulting in minimum time for patients (hospital setting)

Limited staff knowledge to provide adequate care

Education/Upskilling of staff. PHC staff – education on diagnosed cancers, treatment and management. Hospital staff – education on health and hospital associated needs of Indigenous patients.

Patient centred care. Aboriginal Liaison Officer (ALO) providing cultural support and care prior to patient presentation to hospital based on patient-identified needs, use of translators as required

Collaborative practices and proactive attitudes/practices, peer support amongst care providers within and between sectors

Proactive approach to patients care

Patient navigator

Patient support to access services

Systems and processes resulting in barriers to care e.g. organisation protocols resulting in a lot of paperwork and time delays)

Practical support for patients to access care (for example, transport, accommodation, care coordinators/navigators

Collaborative practices across settings to plan patient’s post-discharge care and follow-up prior to hospital discharge

Sharing of electronic patient records across hospital and PHC sites

Seeing the same care navigator/coordinator through the cancer journey across settings to deliver care continuity

Simpler protocols around release of patient information documents for treating PHC services to obtain copies of patient hospital records to be able to provide care continuity and quality follow-up care at the PHC end

Flexible care delivery (e.g. telehealth)

‘Drop-in’ clinics

Extension of clinic hours (PHC)

Longer GP/specialist patient consultations

Visiting specialists/allied health professionals at PHC setting

Rigid hospital appointment schedules/times

Transport and parking costs (hospital setting)

Short hospital consultation times with specialists

Lengthy waiting times before seeing specialist (hospital setting)

Care flexibility (especially at the hospital) and consideration of individual patient needs when scheduling appointments (for example, travel distance), in care delivery (such as telehealth options), availability of outside business hours clinics to access allied health staff, practical considerations (for example, parking costs, public transport).

More consideration for appointment flexibility for patients living outside urban areas

More time allocated for specialists’ consultations

Active follow-up of patients who are unable to attend scheduled appointments

Patient support (help with self-management strategies and to prioritise health as needed)

Timely and improved communication pathways between services

Keeping patients informed whilst waiting to be seen in hospital

Timely communication and information exchange

Use of technology

Limited communication & coordination/teamwork within hospital

Delayed communication and information exchange on patient treatment/condition

Ineffective administrative/system processes (such as some PHC having difficulty accessing paperwork)

Sharing of patient electronic records across settings in real time

Timely, frequent and ongoing communication and more use of telephone calls, case conferences between services, specialists providing updates to GP after every hospital specialist appointment (not only for changes and/or to discuss concerns)

Name and contact details of a contactable medical staff member as point of contact on all discharge summaries

Patient information – ensuring patients are aware they can access both hospital and PHC care services after hospital discharge

Streamlined administrative processes and paperwork (for example, streamlined release of patient information consent forms)

Collaborative partnerships, teamwork and good relationships within and external to the organisation

Care management plans

Working in silos

Lack of clarity between PHC and hospital staff on who’s providing the follow-up care

Lack of streamlined services and system processes

Working together, good relationships and follow-up care. Hospital providing discharge summaries and/or paperwork to PHC in timely manner, shared patient management care plans, developing communication protocols between services, more collaboration across multidisciplinary teams in hospitals

Shared patient electronic records across services in real time

Clarity around professional roles and responsibilities (for example, role of ALO and social worker at the hospital) and clarity between hospital and PHC staff on post discharge follow-up care (who is doing what)

Communication/engagement with PHC such as copying GP in relevant communications with specialists, referrals, keeping PHC in the loop

Prompt follow-up of positive test results and communication with GP and relevant professionals

Hospital admission notifications and treatment updates to PHC while patient is hospitalised (with patient consent)

Streamlined administrative processes

Designated site contact person at the PHC and hospital is provided to services as a point of contact for any patient and care related enquires